| NPI | 1760072375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3866) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SC 3866) |
| Enumeration Date | 2021-01-19 |
| Last Update Date | 2021-03-10 |